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Best Laid Plans: Did NHSE’s winter 2022/23 measures make any difference?

Rachel Carter evaluates the success of NHS England plans for general practice this winter

NHS England set ambitious targets for increasing resilience this winter. Among them were plans to reduce crowding in A&E, improve category 2 response times and ambulance handover delays, boost NHS 111 and 999 call handler numbers, and ensure timely discharge from hospital. 

As services near the end of what has been the worst winter they have ever seen; such measures seem far removed from the reality on the ground.

For general practice meanwhile, there were a few commitments – including advising local systems to set up acute respiratory hubs to reduce pressures and a pledge to maximise ARRS recruitment. 

But further investigation by Pulse suggests implementation has been patchy and while ICBs have made some efforts to provide financial support for GPs, not everyone has benefitted. 

Acute respiratory hubs
An influx of respiratory illness after two consecutive winters of lockdown restrictions and an unprecedented increase in demand associated to the strep A outbreak were major challenges for GPs before Christmas. One element of NHS England’s winter resilience plans that did have the potential to provide some relief was the suggestion that systems should ‘actively consider’ establishing an acute respiratory infection hub. But initial progress was slow.

In November, Pulse asked all ICBs if they had set up a hub. Only four of the 25 that responded said their hub was fully operational, while a further six said they were in the process of setting one up. Three had definitively ruled it out, although some were delivering a virtual ward model instead. There were also wider concerns raised at the time about how these hubs would be staffed – including that PCNs in neighbouring areas could be left competing for locums. 

In some areas these have worked well – particularly those set up in inner city locations – although the concerns around staffing have played out with ongoing challenges to recruit. But for others, the set up has been more geared towards secondary care, providing little benefit for GPs.

With the NHS England deadline not until March, more hubs are in the process of being set up. Pulse has learned of another six ICBs that now have one up and running and a further two who are in the process of setting up. For the GPs who have only just seen hubs open in their areas though, they are left questioning whether they will be as much use as they might have been a few months ago. 

It was made clear early on that GPs wouldn’t be getting any extra cash from NHSE this winter – aside from £37m repurposed from deferring or retiring several IIF indicators. NHS England’s national director for primary care Dr Amanda Doyle told the Best Practice conference in October that the financial situation was ‘quite tight’ and there was ‘no access to additional funding coming’.

ICBs were however asked to identify whether they could allocate potential winter support funding – if they could find any – to GP practices and PCNs in their area and to consider how ‘system development funding’, which is allocated annually to local commissioners under the long-term plan, could be targeted to support practices. Some LMC leads told Pulse that ICBs had ‘done what they could’ – finding funding that equated to 46p per patient in one case and 60p per patient in another, which was distributed directly to practices with minimal strings attached. It enabled them to hire extra staff where needed and was used to improve access and manage urgent care demand. 

Others said monies had been given to PCNs to deploy various services, including providing extra resources for practices to hire locums and provide clinics on evenings and at weekends. This has been appreciated, but in some areas it has been implemented at such short notice that practices have ‘almost had to get the plans in place and have spent the funding’ before they even received it. 

Meanwhile in Lincolnshire, the LMC wrote to the ICB at the end of January expressing concern about ‘the level and constancy of support provided to them so far during this winter period’. The letter, seen by Pulse, highlighted confusion in the communications about what funding would be coming to general practice and said the lack of confirmation had left practices to make locum bookings at their own financial risk or ‘cancel those bookings and risks relationships’ with the locums.

Some ICBs have taken to support practices over the winter by offering QOF income protection. Devon was the first to make the move, with the ICB committing to income protect QOF for 2022/23 to enable practices to use their clinical judgement on how best to prioritise workload and workforce ‘without concerns around the potential financial impact’. Its initial plans to suspend QOF wholesale were blocked by NHS England, which Pulse understands has also since clamped down on other areas who were looking to take a similar approach. But Devon was able to agree a ‘package of support’ to allow GPs to prioritise demand without financial detriment.

Other ICBs have also managed to reach a similar deal: Derby and Derbyshire, West Yorkshire, Mid and South Essex and Suffolk and North East Essex, Norfolk and Waveney, and Cambridgeshire and Peterborough, have all taken steps to offer to meet the losses from QOF incurred by practices over the winter months as a result of prioritising urgent demand. 

Reducing urgent care pressures
NHS England had vowed to reduce crowding in A&E departments and target the longest waits in emergency departments. However, NHS performance data showed a record 54,500 patients per week were waiting longer than 12 hours in A&E in December following decision to admit. 

Its promise to target Category 2 response times and ambulance handover delays failed miserably. In December Category 2 ambulance calls took on average more than an hour and a half against a target of 18 minutes. This dropped to just over half an hour (32 minutes) in January 2023. 

When asked about its target to increase the number of call handlers to 4,800 in 111 and 2,500 in 999, NHS England told Pulse it does not publish data on this but said that as all the measures in its plan were for March, there was ‘still some time to go’. 

Additional roles recruitment
The plans included maximising recruitment of new staff in primary care across the winter, including care co-ordinators and social prescribing link workers

Of the 15 ICBs who responded to Pulse’s query on this element of the plan, 11 said they had scaled up additional roles reimbursement scheme recruitment – though this seemed to be simply continuing the rollout of the national scheme. Bedfordshire, Luton and Milton Keynes said it had appointed a ‘Personalised Care Ambassador’ who is supporting with recruitment, induction, supervision and retention. Humber and North Yorkshire ICB said it had a ‘workstream’ that supports at-scale recruitment opportunities, and had held events for social prescribers.

Of the remaining three, two did not say whether they had done anything specific on this, and one said it had already met its share of the target on ARRS recruitment.

Again, when asked about this point, NHS England said it did not publish this information. Some GPs told Pulse that they weren’t aware of any new initiatives to boost recruitment. Others said that a mention in the plan always helps to push things forward a bit, but recruitment had already been underway before it. 

Most importantly, the ongoing challenges around securing the right ARRS staff also still remain. 

The latest figures on the scheme show 25,262 additional staff have been recruited to primary care since March 2019, including 4,105 in direct patient care roles. 

Community-based falls services
The plans said: ‘All local systems should have a community-based falls response service in place between 8am and 8pm for people who have fallen at home including care homes. The service should be in place by 31 December 2022 and be available as a minimum 8am-8pm 7 days per week.’

Of the 15 ICBs who answered, 14 told Pulse they had implemented this service by the December deadline, but in some cases such a service was already in place long before this. 

Humber and North Yorkshire said community-based falls response services were in place across the ICS footprint before December 2022, with work underway to enhance these ‘in line with requirements’ contained in NHSE’s winter resilience plan. 

One LMC lead commented that the falls service in their area had been in place for a while and was ‘not bad’ but added: ‘The issue is not just having an assessment done, it’s the ongoing treatment of patients, especially the elderly in nursing homes and their own homes. How good is the infrastructure? How good is the social care infrastructure to support people independently living at home safely? That’s where the problem is.’

Frequent attenders support 
NHS England called on ICBs to ‘consider targeted, proactive support for people who have high probability of emergency admission, sometimes called High Frequency Users. For example, work in one area identified that 1% of people (~600 people) accounted for 1,925 ED attendances and 54,000 GP encounters over a 12-month period.’

Cambridgeshire and Peterborough said it had ‘initiatives in place that are specifically geared towards avoiding hospital admissions’, while Somerset ICB said its ‘Urgent Community Response’ and ‘Virtual Ward’ teams are aiming to ensure patients are responded to within two hours. Derby and Derbyshire said it had ‘produced a dashboard which maps a patient’s journey’ through ambulance services, 111, acute trust, mental health, community and primary care, which includes a data sharing arrangement. 

Of the 15 ICBs who answered, 13 told Pulse they had implemented initiatives to support frequent attenders, and a further one said this was currently under development.